In the past couple weeks, we’ve written extensively about the growing opioid epidemic and its consequences on both the consumer population and the health care system (see Addiction & Hospital Utilization – The Endless Loop? and Opioid Addiction – The Crisis, The Impact & The Responses). One way the Centers for Medicare & Medicaid Services (CMS) and state Medicaid programs are trying to combat this problem is through the substance use disorder (SUD) delivery system transformation waiver.
The goal of the demonstration is to improve care for consumers with SUD by encouraging states to develop a more robust SUD delivery system. To do this, states can expand their Medicaid SUD treatment benefits, improve care coordination and integration strategies, and use the American Society of Addiction Medicine (ASAM) criteria to determine service needs of consumers (see State Medicaid Director Letter (SMDL #15-003) New Service Delivery Opportunities for Individuals with a Substance Use Disorder).
The biggest change associated with the demonstrations is the expansion of the Medicaid SUD residential treatment benefit, which waives the institution for mental disease (IMD) exclusion for up to 30 days. (Under the IMD exclusion, CMS does not allow Medicaid reimbursement for services provided to consumers between the ages of 21-64 in facilities with more than 16 beds that primarily serve consumers with mental illness or addiction.) In addition to the expansion of residential treatment benefits, the most common benefits states are adding to expand their SUD delivery system are recovery support services and non-hospital based withdrawal management.
The demonstration has been gaining considerable traction among state Medicaid programs, with at least eight states submitting demonstration waivers to CMS. But how much impact will these waivers make on access to treatment in the states that have adopted them? That is the focus of our new market intelligence report, An Update On States With Medicaid 1115 Waivers For Addiction Treatment. The report includes:
- A review of the SUD delivery system demonstration requirements and their strategic implications for the addiction treatment market
- A state-by-state chart detailing the demonstration in each state – including the populations eligible for the demonstration, the geographic availability of services, how the state is using the American Society of Addiction Medicine (ASAM) criteria to determine eligibility for SUD benefits, and details on the additional SUD benefits each state is covering under the waiver.
- A market analysis of the population newly eligible for the enhanced benefit and the size of the population most likely to utilize the new benefits in each state
- A review of the quality measures each state will use to monitor the success of their demonstration program
Our analysis found is that in the eight states with the expanded waivers, about 8% of the population has expanded access to residential addiction treatment options (and the other added Medicaid addiction treatment benefits) and in some states this climbs to 12% of the population. Diving a litter deeper, about 0.9% of consumers in those states have a substance use disorder that may qualify them for these services. That means there are 800,000+ people in eight states who have an addiction problem – and are now eligible for an expanded benefit package, including residential addiction treatment.
As health plans and provider organizations consider the adequacy of available addiction treatment systems, the impact of Medicaid policy and the demand of Medicaid beneficiaries needs to be considered. Our analysis provides the framework for addiction treatment planning in the three states with approved demonstrations (California, Maryland, Virginia) and the five states with pending demonstrations (Illinois, Indiana, Kentucky, Michigan, West Virginia). For more on service line development, check out Diversification & New Service Line Development and New Service Line Development From A To Z: Tips, Tricks, & Advice.
If you’re looking for a deep dive into expanding your services, join us June 7, 2017, in New Orleans at The 2017 OPEN MINDS Strategy and Innovations Institute for the session, “Strategic Revenue Diversification: The HealthPath Commercial Health Home Case Study,” with Joseph P. Naughton-Travers, Ed.M., senior associate at OPEN MINDS, and Ian Lang, executive director of Continuum Behavioral Health.
And for more news, analysis, and updates, follow me on Twitter @athena_mandros.